Older Folks and Vaping Back Porch - Part Five

[Kaezziel]

I know it Brother, just like you and your bride are always in mine.

And I appreciate it immensely! We're actually fighting with the insurance company right now. So far, they've denied covering her new chemo med. Twice. We appealed the first denial and they denied it again. Now the doctor is sending over a "Medical Necessity" form in an attempt to get them to sign off on it. If they deny it this time we'll have to pursue other options. The hospital has a group that helps in cases like this, and also the drug manufacturer has an assistance program. We're just hoping that the insurance comes through first, but if not, we'll figure something out.

 

[Kenna]

still feeling a bit off today, so...
everyone wants you to think their Bae is the wonderful significant other.
What does Bae mean

http://www.wordsense.eu/bæ/

In Swedish it means s***.

 

[Kaezziel]

Well... to be fair, in the sense that Ken is using it, it is an acronym.
B.A.E.
Before Anyone Else

 

[LittleBird]

I'm off n running around town in a little bit..Dr's, P.O., pharmacy ,Sec. of state, Walmart...


I already need a nap just thinkin of it

Please do say hello to Sec. Kerry for me

@Kaezziel - What she said. Same as I believe - our lives are molded as we enter each day, but that does not mean that you will not make small decisions in life that you wish you could change.

What is the old saying - Hindsight...

Is 20/20. But there's another, equally good (perhaps better) one: Life's a whole lot easier from the bleachers. I bet your daughter loves you great enormous big bunches!

I understand this completely. Accepting that it isn't your fault when something happens to one of your kids is very different from accepting that it did happen.
I'm glad you realize it isn't your fault, I still struggle with that at times. But I also understand wishing you could change it, because if I could go back in time and change one thing, I know exactly what I would want to change.

Don't we all, Kev. I'm afraid I can't agree with all the folks who say they wouldn't change a thing, even with foreknowledge. There are nights that I lay awake, thoughts of things I've done about which I'm ashamed running through my head. I know I'm forgiven, but forgiving myself is a whole 'nother ball game. If I could take a mulligan or twelve, I'd do it in a heartbeat!

And I appreciate it immensely! We're actually fighting with the insurance company right now. So far, they've denied covering her new chemo med. Twice. We appealed the first denial and they denied it again. Now the doctor is sending over a "Medical Necessity" form in an attempt to get them to sign off on it. If they deny it this time we'll have to pursue other options. The hospital has a group that helps in cases like this, and also the drug manufacturer has an assistance program. We're just hoping that the insurance comes through first, but if not, we'll figure something out.

The Insurance Commissioner is the next stop, Kaz. Insurers don't like being brought to the attention of the State Insurance Commissioner - especially in an election year.

 

[Kaezziel]

The Insurance Commissioner is the next stop, Kaz. Insurers don't like being brought to the attention of the State Insurance Commissioner - especially in an election year.

Hmmm... I'll have to look into that. Our insurance is private insurance through the company and managed by an outside party. Basically, the state doesn't have anything to do with our insurance. All of the money that they pay out is directly from the company. Makes things a little dicey when you want to contest something because I don't want to bring too much attention to stuff when they are laying people off around here.

 

[LittleBird]

Hmmm... I'll have to look into that. Our insurance is private insurance through the company and managed by an outside party. Basically, the state doesn't have anything to do with our insurance. All of the money that they pay out is directly from the company. Makes things a little dicey when you want to contest something because I don't want to bring too much attention to stuff when they are laying people off around here.

It sounds as though your employer's plan is self-funded, and uses an insurer to administer the plan. It probably has a stop loss provision, as well, so that if claims exceed some threshold, the company can pass along the cost to a secondary insurer. Regardless, the plan must conform to federal requirements regarding coverage, and must have a conforming appeals process. Additionally, HIPAA precludes your employer from being in any way involved in the claims process. That'd be a very quick road to ginormous fines and jail.

 

[Debadoo]

And I appreciate it immensely! We're actually fighting with the insurance company right now. So far, they've denied covering her new chemo med. Twice. We appealed the first denial and they denied it again. Now the doctor is sending over a "Medical Necessity" form in an attempt to get them to sign off on it. If they deny it this time we'll have to pursue other options. The hospital has a group that helps in cases like this, and also the drug manufacturer has an assistance program. We're just hoping that the insurance comes through first, but if not, we'll figure something out.

Wow.....I would say that just makes me sick.....and it does, but the insurance co prolly wouldn't cover the illness! Definitely hope they approve it.....or........another entity comes forward and you won't even have a co pay, it'll be totally covered!!!! Use that co pay money for mental health fun things for both of you!!

Well... to be fair, in the sense that Ken is using it, it is an acronym.
B.A.E.
Before Anyone Else

Thanks had no idea how that referred to a significant other

The Insurance Commissioner is the next stop, Kaz. Insurers don't like being brought to the attention of the State Insurance Commissioner - especially in an election year.

Jup!! Excellent point.

Makes things a little dicey when you want to contest something because I don't want to bring too much attention to stuff when they are laying people off around here.

Another excellent point!! Jup that's the bottom line, but pretty sure the ins commis oversees all insurance coverage

 

[Kenna]

No...my heart just hurts

I don't think anyone got heated at the actual Mod's, Classy. My ire was raised by the button pusher. I know that pushing that button can lead to things we don't want to happen to anyone here. Ever. For any reason. I don't want to know who did it. I don't care if it was a Porch regular, or someone not familiar with any of us & just cruising the forums looking for things that in their opinion might be construed as breaking a rule. It was a frigging cartoon for pete's sake. I've seen things much "worse" posted & discussed here & no button pushing occurred. Some chose to hit the switch rather than pm the "offender", which is usually what happens. Or even openly address it on the thread, which has also been done. But none of that happened. They went straight to report which should only be for completely outrageous posts, emergencies, & last resort. That is why I was/am upset. It's not because of the OP, or the subject matter. It's because someone needlessly pulled the trigger befor using the other options.
No one is picking on the actual Mod's.
Be careful what you post here, Porchers. No telling when someone is going to have a pissy, judgemental attitude & hit that button. Please note, I'm saying all this in the open for anyone to see. Not hiding in the dark taking pot shots.

 

[Debadoo]

Be careful what you post here, Porchers. No telling when someone is going to have a pissy, judgemental attitude & hit that button. Please note, I'm saying all this in the open for anyone to see. Not hiding in the dark taking pot shots.

Jup!

 

[Kaezziel]

It sounds as though your employer's plan is self-funded, and uses an insurer to administer the plan. It probably has a stop loss provision, as well, so that if claims exceed some threshold, the company can pass along the cost to a secondary insurer. Regardless, the plan must conform to federal requirements regarding coverage, and must have a conforming appeals process. Additionally, HIPAA precludes your employer from being in any way involved in the claims process. That'd be a very quick road to ginormous fines and jail.

Yep, that's exactly how our plan is set up. They do have a standardized appeals process; that's what we're going through right now. It's just frustrating that the insurance company people would continue to deny coverage after getting a letter from the doctor. The next (and current) step is for the doctor to send another letter stating "medical necessity" and laying out what other options have already been pursued and why some options aren't being considered. Hopefully that will be the end of it, but I'm not holding my breath. It is good to know that HIPAA applies and keeps the insurance from passing info along to corporate. I wasn't positive as to whether or not that was the case.

Wow.....I would say that just makes me sick.....and it does, but the insurance co prolly wouldn't cover the illness! Definitely hope they approve it.....or........another entity comes forward and you won't even have a co pay, it'll be totally covered!!!! Use that co pay money for mental health fun things for both of you!!

Hahahaha! You're prolly right. They wouldn't cover that.
We'll see what happens... we've managed to handle everything so far, this is just another hurdle that we have to jump through...

Thanks had no idea how that referred to a significant other

No problem... I didn't know either, when I first saw it. Had to look it up...

Another excellent point!! Jup that's the bottom line, but pretty sure the ins commis oversees all insurance coverage

Looks like that's not gonna be an issue...

 

[LittleBird]

@Kaezziel, not meaning to be a PITA. I'm sure you've read your medical plan docs several times. I just want you to know that HIPAA provides protection far beyond those with which the general public is familiar. Similarly, the Affordable Care Act reaches into all health plans, including those that are self-funded. Grandfathering pretty much ended 1/1/14; by 1/1/15, except for the religious beliefs carve out, ACA governed the design of all plans. The only way out would be if your company did not take the tax credit for offering coverage -- and there isn't a single company in the country that opted for that. Exhaust every appeal!

 

[Kenna]

I'm off n running around town in a little bit..Dr's, P.O., pharmacy ,Sec. of state, Walmart...


I already need a nap just thinkin of it

Have some fun in there somewhere, Kay! Take pics at Walmart, bound to be some good ones!

 

[DancingHeretik]

still feeling a bit off today, so...
everyone wants you to think their Bae is the wonderful significant other.
What does Bae mean

http://www.wordsense.eu/bæ/

Well... to be fair, in the sense that Ken is using it, it is an acronym.
B.A.E.
Before Anyone Else

I hear it's popular to use nowadays in place of 'baby'. It may mean 'before anyone else'. But,the fact that it sounds so much like 'baby' is what reminds people to keep saying it.

 

[Kenna]

ohhhhh that sounds sooooo good!!!


hehehe I know but but but.......well I'll leave it for Dave's post


No I think it's wonderful!!! Just was surprised! Most men either don't like animated films, or won't admit it if they do. I was thrilled to see so many.


Me too. for dil's mom.


we'll be doing some hangouts hint hint can't recall if you said you didn't have a camera, mic or both, dunno.


Me either. My picker was and likely still is broke!!


I'm in big trouble then........I couldn't read that straight while stone cold sober!!


Ok, here's matt's

I don't doubt I misread it, but I still am. I'm reading "dude who's in Boyz to Men and is a deaf dude." But, I did just now look it up......and they are two different people. But this is where I got cornfuzzled. Sure sounds like he was saying the Boyz II Men guy is deaf.


Jup.....love it. My current fav isn't really funny and I only saw it once, but it was a guy who got a truck.....somehow he ended up takin it muddin.......had a blast, pulled up in the driveway, both he and the truck were filthy but he had a huge smile on his face!!!


Wahooooooooooo very happy about that!!! Now make the doc give you something non narcotic that will help with pain. It's just a muscle relaxer, but the only thing that has helped me even a little (and I've been on a lot of muscle relaxers over the years) is skelaxin/metaxalone. Dunno if another would help you better or not


i LOVE magnolias!!! and wow that thing is huge!!


oomgggggggg that was soooooo cute!! Had to send that one to my son, he has always loved pugs. The pics of your baby girl were adorable too!! Feels like I spend about 1/2 my life rubbin Frankie's belly. Bet you do too with her.


no your not, I'm with Dave, it's disgusting!


wahoooooooo we can help ya in the hangout get the gist of the coiler. and with everything else. But I'm still hopin you might be able to stop by the tiki house for a day also. Better in person. We'll get ya totally up and runnin with it either way.


((((((((Semi))))))))))) I'm so sorry darlin!! I hope you know it's not your fault though.


(((((((((((Ken))))))))) sorry you're feeling bad. I've never heard someone use Bae, except for on Once upon a time. Rumplestiltskin called his son that.


You make a storm sound so beautiful!! I do love thunderstorms or any storm, when it's not a super dangerous one. The fury of nature can be mesmerizing!


(((((((Classy))))))))) did we do that to you, or just compound something else that made your heart hurt? Either way, I'm so sorry.


Jup!!! You and Gracie said what I wanted to say. As hard as some things were, they made me who I am, and I like who I am. Took me a very long time to be able to say that. Do I like everything.....newp, but I'm still a work in progress......but overall, I'm content.

Not "and is". He said "as is".

 

[Kaezziel]

@Kaezziel, not meaning to be a PITA. I'm sure you've read your medical plan docs several times. I just want you to know that HIPAA provides protection far beyond those with which the general public is familiar. Similarly, the Affordable Care Act reaches into all health plans, including those that are self-funded. Grandfathering pretty much ended 1/1/14; by 1/1/15, except for the religious beliefs carve out, ACA governed the design of all plans. The only way out would be if your company did not take the tax credit for offering coverage -- and there isn't a single company in the country that opted for that. Exhaust every appeal!

Oh, Sweetie... you are NEVER a PIMA! Yes, I've read through most of the documentation. I'm also pretty familiar with HIPAA because I'm a "First Responder" at work and they drill HIPAA into our heads, I just wasn't sure how it played into the insurance/company relationship. Much of the ACA is beyond my knowledge. I haven't dug into that at all. We will exhaust every appeal though. Along with each and every other option available to us. Thank you for your insight, Dearest. Please believe me when I tell you that it is valued and appreciated.

 

[Von Vape]

Take pics at Walmart, bound to be some good ones!

Oh ya! Love those WallyWorld pics!

There's an irony in there though. People are always saying, "Get a load of the kind of people who shop at Walmart!".
But the people who take the pictures HAVE TO BE IN WALMART!

Love the pics! DO SHARE!

Oh ya, Good Morning All! (10 A.M. AST)

 

[Kenna]

And I appreciate it immensely! We're actually fighting with the insurance company right now. So far, they've denied covering her new chemo med. Twice. We appealed the first denial and they denied it again. Now the doctor is sending over a "Medical Necessity" form in an attempt to get them to sign off on it. If they deny it this time we'll have to pursue other options. The hospital has a group that helps in cases like this, and also the drug manufacturer has an assistance program. We're just hoping that the insurance comes through first, but if not, we'll figure something out.

Have you tried calling the ins co & speaking directly to them about the exact reasoning behind the denial? How about climbing their supervisory ladder?

 

[bigbells]

dude who's in Boyz to Men and is a deaf dude

Except that's not what Matt's post says. You quoted it but then when you rewrote it you wrote something different than what Matt had written. Read Matt's post again, and read it right this time!

 

[Kenna]

Hmmm... I'll have to look into that. Our insurance is private insurance through the company and managed by an outside party. Basically, the state doesn't have anything to do with our insurance. All of the money that they pay out is directly from the company. Makes things a little dicey when you want to contest something because I don't want to bring too much attention to stuff when they are laying people off around here.

That doesn't matter, Kazz. They still have to follow State & Federal Law. The Commission makes sure that happens. They don't want to be brought to the attention of that agency. You could also call the office of your Senator for help.

 

[Von Vape]

Except that's not what Matt's post says. You quoted it but then when you rewrote it you wrote something different than what Matt had written. Read Matt's post again, and read it right this time!

Hi bigbells! I suspected you were correct. When I read what Debadoo wrote, it just didn't seem to jibe. Then your post caused ME to backtrack and find it. So, to save time, here is the EXACT quote as originally written...

The got this huge black dude who's in Boyz to Men who is absolutely fantastic as is a deaf dude.

Unlike the Facebook Film Petition, a comma may have been appropriate (between the words "fantastic" & "as is a deaf dude.").

Moreover, I'm pretty sure it was just a brain fart on Debadoo's part, anyway. Happens to me ALL THE TIME! I probably need MORE NICOTINE!